Published in the January 2016 issue of Today’s Hospitalist
As is the case with nearly every other patient population, hospitalists have become the default admitters and attendings for psychiatric patients. It is a role they’ve taken on despite scant training in psychiatry and, in many nonacademic community hospitals, little to no back-up. It’s no wonder that more than one-third of hospitalists confess to being uncomfortable when admitting psychiatric patients, according to the 2015 Today’s Hospitalist Compensation & Career Survey.
It’s classic “scope creep,” points out Jacques Burgess, MD, MPH, section chief for hospital medicine at Munson Medical Center in Traverse City, Mich., and a hospitalist with iNDIGO Health Partners. “The ED calls us first because we are trusted and readily available. We want to be the go-to resource, yet we may not be the best suited for the patient with acute psychiatric needs.”
Dr. Burgess figures that when he works nights, particularly on weekends, he admits at least one patient with behavioral issues every shift. “You are sending tox screens, using restraints and trying to work through them the next day,” he adds. He estimates that as many as 60% of the patients hospitalists admit who need prompt evaluation by a psychiatrist would benefit from a med-psych unit.
“You may over-support rather than under-support so you don’t put your staff at risk.”
But without such a ward or service, hospitalists are left “prescribing medications and sedating people, and you may over-support rather than under-support so you don’t put your staff at risk,” Dr. Burgess notes. “Maybe you give too much medicine and now someone is sleepy and not eating, and your length of stay and risk of falls and aspiration go up.”
Despite that vicious cycle, the issue no longer is whether hospitalists “should” be treating patients with serious psychiatric conditions, but “how.” And shifts in reimbursement are now forcing administrators to take a new, hard look at this patient population and to challenge both hospitalists and psychiatrists to improve their care.
Barriers to transfer
Too often, says Ilan Alhadeff, MD, vice president of TeamHealth Acute Care Services, which employs more than 4,000 hospitalists in hospitals throughout the country, psychiatric patients get admitted to the hospitalist service from the ED and need to be cleared medically before they go to a psychiatric unit.
But there are many barriers to transferring these patients to an inpatient psychiatric unit. “These could include abnormal lab values, elevated blood sugars or blood pressures, delays in psychiatric evaluations on the medical unit, or simply a lack of psychiatric-bed availability,” Dr. Alhadeff says. To be fair to psychiatrists, he adds, “many psychiatric illnesses are medically induced, not to mention that psychiatric patients also have real medical conditions that require treatment.”
As for hospitalists, treating psychiatric patients could make them “feel dissatisfied because they can’t necessarily fix everything, and doctors like to fix things. It’s not like giving an antibiotic,” says Dr. Alhadeff. “Also, these are patients who can consume a lot of time, which is something that hospitalists are limited on.”
If you consider substance abuse and withdrawal, depression and suicidality, delirium and dementia, and the entire gamut of medical comorbidities that psychiatric patients present with, “probably 30%” of the hospitalist service’s daily census at Parkland Memorial Hospital, Dallas’s large nonprofit safety-net facility, have a primary or comorbid psychiatric complaint. That’s according to Roberto de la Cruz, MD, hospital medicine division chief and an assistant professor of medicine at University of Texas Southwestern Medical Center.
For Dr. de la Cruz, improving care starts with adjusting the attitude of all members of the treatment team, including a significant number of hospitalists. The motivation to improve is often prompted by a crisis. At Parkland, for instance, the hospital was threatened with the loss of federal funding for being out of compliance with Medicare’s rules regarding protecting patients from self-harm.
That’s when the administration began putting pressure on both the hospitalists and psychiatrists to figure out how to better coordinate care. The two services are now drawing up a comanagement agreement to improve both the psychiatric care provided to medical patients assigned to a small secure unit staffed by hospitalists and the medical care delivered to psychiatric patients in the hospital’s small psychiatry inpatient unit.
“At least twice a week, we’ll have a huddle,” Dr. de la Cruz explains, “so the psychiatrists will go over the patients in their unit and we’ll go over the patients in our unit to identify opportunities to help each other out.” Psychiatric-overlap patients, he adds, sometimes need a different skill set, and clinicians need to “recognize the triggers” that might make a patient become dangerous. “The plan is to decrease incidents by figuring out ahead of time the patients who may pose problems.”
Money is also driving other efforts to improve care coordination because med-psych patients are so costly. For insurers, the cost of treating patients with behavioral health issues can be three times higher or more than for comparable patients without such conditions, with most of those costs for medical services. Patients with behavioral health issues also have longer lengths of stay and higher readmission rates.
In New Hyde Park, N.Y., Long Island Jewish (LIJ) Medical Center saw an excessive number of readmissions posted by patients who kept bouncing back and forth between a neighboring psychiatric facility—Zucker Hillside Hospital—and LIJ’s medical units. That led hospital administration to put the hospitalists and psychiatrists on notice.
Physicians came up with a two-pronged solution. They first created a 15-bed hybrid medicine and psychiatric unit in the hospital that is staffed by a full-time hospitalist, hospitalist nurse practitioner, psychologist, nurse manager and specially trained nurses, aides and patient engagement specialists. There are daily multidisciplinary rounds and 24/7 access to psychiatry consultants.
Second, hospitalists developed a new consult service at the psychiatric hospital, where LIJ’s 70 hospitalists never had rotated before. Two hospitalists at a time—drawn from a small subset of interested physicians—work two-week, Monday-through-Friday stretches at Zucker Hillside, plus some weekend coverage. LIJ’s nocturnists also began providing night-time phone support (and, if needed, onsite visits) to the psychiatric hospital.
“Before, the psychiatric hospital would just ship patients with medical issues to the ED, and now they have to run it by us before they do,” explains Corey Karlin-Zysman, MD, chief of LIJ’s hospital medicine division. Since October 2014, when the consult service started, the readmission rate of patients from Zucker Hillside has dropped from 25% to 12.5%.
“We are more like comanagers over there, handling all the Coumadin for the psychiatrists and making sure the sugars don’t get to 300.” Dr. Karlin-Zysman says. “We are much more hands-on and aggressive, and that has allowed us to drop the back-and-forth. They now have 24/7 access to us in some way, shape or form.”
A different skill-set
As for the 15-bed hybrid unit, Dr. Karlin-Zysman explains, the administration saved enough money from reducing (by almost half) the need for one-to-one continuous observation that it agreed to fund additional clinical staff and training.
The new unit also dramatically decreased the number of patients with restraints (18.2% to 1.7%) and readmission rates (27.6% to 18.2%), says Katherine Lerner, MD, the unit’s lead hospitalist. She staffs the unit full time, with several other hospitalists filling in when she is away.
“The biggest part of the unit’s success is that the people there have an interest in working with this patient population,” says Dr. Lerner, who adds that the service is not for everyone. “You have to be patient and know how to deescalate and work the situation, because patients can be manipulative.” You also have to know what to do when patients refuse to eat or take insulin, and you need to limit the number of providers.
“It can be confusing to patients to have providers coming in and out of rooms,” Dr. Lerner points out.
Before the unit was created, “a person would end up in the hospital for two weeks rather than five days,” she says. Patients acting out would be sedated, sleep through breakfast and lunch, then wake up at dinnertime agitated. “So a patient gets more meds and it becomes a cycle. He is dehydrated, we have to give him fluids and then his kidneys are working hard, so he goes to the ICU and is sedated even more. It snowballs.”
While some “informed hospital systems” are creating hybrid units and comanagement arrangements, Roger Kathol, MD, a dually trained internist-psychiatrist and past president of both the Academy of Psychosomatic Medicine and the Association of Medicine and Psychiatry, says that these are still far and few between.
But Dr. Kathol is optimistic that the impasse is finally changing. He sees the Affordable Care Act’s new financing rules as “stimulating” an integration of behavioral and medical health programs by including behavioral services as part of medical insurance benefits, a single payment pool his consulting firm—Cartesian Solutions, based in Burnsville, Minn.—promotes.
“The ACA and ACO model are forcing a rethinking about how behavioral health is delivered in the medical setting,” he says. “Hospital systems that are now accountable for total patient population costs recognize that they had better address the complicated, high-cost, comorbid patient.”
The challenge? Most hospital systems and insurance companies have for decades organized (and paid for) behavioral health care and medical care separately. Many, he says, “don’t understand how to put behavioral health back into their systems.”
Dr. Kathol mentions another integrated model that is helping hospitalists: proactive psychiatric consult teams.
“Teams of hospitalists and psychiatrists, often with psychiatric nurse practitioners, screen everybody—sometimes in the emergency department, sometimes on the floors—and do behavioral evaluations on the day of admission, rather than waiting for a hospitalist or specialist to refer to them,” he says. Such teams, Dr. Kathol points out, have significantly reduced the use of sitters. Yale New Haven Hospital also successfully cut costs and length of stay with just such a model, described in an article in the November-December 2011 issue of Psychosomatics.
New contracts with psychiatrists
Duke University Hospital in Durham, N.C., has recently succeeded with another model: hiring a full-time psychiatrist to work in the ED. According to Jane Gagliardi, MD, a dually trained internist and psychiatrist who’s associate professor at Duke University, this helps hospitalists in two ways.
First, it begins the evaluation and management of these patients sooner in a hospital stay. And second, adding another member to the team—which previously consisted of a nurse practitioner and a social worker—in the ED during the day increases the ability to evaluate patients in follow-up and permit patients to be discharged from the ED without going to inpatient psychiatry.
Dr. Gagliardi is also part of the psychiatric consult service that contracts with a nearby Duke-owned community facility, Duke Raleigh Hospital. One of a small number of psychiatrists is now onsite there every weekday from 8 a.m. to 5 p.m. to help the hospitalists.
“Psychiatric consultation there used to be catch-as-catch-can, and the hospitalists would have to call around to see if someone in the community was willing to come over,” she points out. “Now, the hospital medicine folks who are uncomfortable taking care of psychiatric patients like it much better if they know there is a psychiatrist onsite who, when they put in a consult, will do it in real time.”
Telepsychiatry is another strategy helping hospitalists in community hospitals without access to flesh-and-blood psychiatrists. Hospitalist Nitin Sawheny, MD, TeamHealth’s regional medical director for Oklahoma and Texas, is creating a telehospitalist platform for TeamHealth that is expected to roll out in 2016. “Telehealth can definitely help hospitalists make an appropriate diagnosis and get medications aligned,” he says.
Many times, Dr. Sawheny points out, “psychiatric patients come in with a whole laundry list of psychotropic meds, and a hospitalist isn’t trained to determine which ones they truly need and which could be causing issues.”
This is the kind of question that hospitalists could easily use telepsychiatry to answer, in addition to making a diagnosis.
“You shouldn’t blindly treat someone with medication, which lots of times hospitalists feel they are doing: using broad-spectrum antipsychotic medications as a band-aid,” says Dr. Sawheny. When providing a diagnosis, he adds, “Hospitalists wonder if we are doing a true service to these patients. That diagnosis could follow patients for a lifetime and hinder them in the future.”
Many hospitalists also worry about how uncoordinated care of patients with dual diagnoses can affect the performance metrics they are evaluated and sometimes paid on. Duke’s Dr. Gagliardi recommends adopting protocols and clinical pathways such as the validated nurse-driven CIWA (Clinical Institute Withdrawal Assessment for Alcohol) protocol or delirium prevention and treatment programs.
Dr. Burgess in Michigan is involved in his hospital’s new initiative to “revisit the issue of restraints.” He wants to craft a protocol that would allow nurses to begin to withdraw physical restraints gradually as patients’ behavior improves. He also plans to reach out to psychiatry and see if together they can create a pathway for stepping down chemical restraints. A next step would be figuring out how to cohort patients into a more efficient, mini medicine-psychiatry unit and reduce the need for sitters.
“Medicine units don’t have the physical set-up that is best for people who are acutely unwell psychiatrically, and the sitter is a phenomenon of that safety piece,” says Kristen Sparks, MD, a psychiatric hospitalist who now works in New Zealand after being a consultant psychiatrist at hospitals throughout Minnesota and Montana. She predicts the cost of sitters will be a “a huge driver for getting things changed.”
As for what reforms hospitalists need, Dr. Sparks mentions two friends who work as hospitalists in rural Indiana. They have no integration with any nearby psychiatric hospital and no consult service to turn to for support.
Sometimes, “they call and try to get a consult,” from community-based psychiatrists, but it “rarely” happens. “They do the best they can,” Dr. Sparks says, “but I don’t want people to be afraid of my patients. I think that sometimes their psychiatric illness gets in the way of them getting the best medical care.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
Ways to improve med-psych care
PATIENTS WITH comorbid psychiatric conditions are no doubt among the most difficult for hospitalists to handle. But what if your hospital can’t create special med-psych units or proactive psychiatric rounding teams? Experts offer these tips:
- Create better relationships with psychiatrists, whether through formal comanagement arrangements or by cultivating curbside relationships. “Internists don’t usually need me to write up a three-page consult,” explains psychiatrist Kristen Sparks, MD. “They want to know, ‘Can I give this patient IV Haldol, how much and will that help?’ When resources are limited, making a personal connection pays off.”
- Ask the right questions and use psychiatrist consultants at the “top of their license,” recommends Duke University’s psychiatrist-internist Jane P. Gagliardi, MD. “If you can get someone to come only one day a week, be judicious about whom you ask them to see. Don’t overwhelm them with 20 consults, with four of those for things like, ‘It would be nice if this patient had an antidepressant and outpatient follow-up.’ “
- Bone up on some basics, such as your state laws concerning holding psychiatric patients against their will and informed consent and refusal. “I don’t mind getting questions about psychiatric diagnoses and psychiatric meds, but sometimes hospitalists ask consultants things they know the answer for “particularly questions like, ‘Does this patient have the capacity to make an informed refusal?’ ” says Dr. Sparks. “Actually, internists are really good at that. They just don’t trust themselves.”
- Encourage case managers and discharge planners to specialize in behavioral health issues. When it comes to locating rehab facilities or outpatient follow-up care, “It’s hard to find places for people with dual diagnoses, and there are frequently insurance barriers,” says Dr. Gagliardi. Not having a place to safely discharge these patients can add significantly to lengths of stay. Having a case manager who knows the community and who gets involved from the beginning of a patient’s hospital stay can help.
- Include a psychiatrist or a psychiatric nurse who works with a psychiatrist in multidisciplinary rounds. Most social workers in hospitals are “not mental health professionals and have limited capabilities because of their training,” says internist-psychiatrist and consultant Roger Kathol, MD. As a result, they aren’t effective at assessing or assisting patients with psychiatric needs. That in turn, says Dr. Kathol, contributes to limited medical or behavioral improvement and longer hospital stays.
- Develop protocols, particularly for prevention, such as those that target delirium or that may prevent patients in withdrawal from developing fulminant delirium tremens. “It starts with recognizing that a person is at risk and putting them on a protocol in the first place,” Dr. Gagliardi says.